This document discusses common side effects of chemotherapy and strategies for prevention and management. It covers nausea and vomiting, myelosuppression, fatigue, taste alterations, diarrhea, constipation, alopecia, stomatitis, cardiotoxicity, neurotoxicity, renal toxicity, pulmonary toxicity, and effects on sexual and reproductive function. Guidelines for antiemetic use include serotonin receptor antagonists, dexamethasone, aprepitant, and benzodiazepines depending on timing of nausea. Hydration, diet modification, and antidiarrheal or laxative use can help manage gastrointestinal issues.

1.  
Continuing Education

2.  Nausea and vomiting:
o Nausea and vomiting are two of the most common side effects
of chemotherapy.
o Vomiting is a reflex controlled in the emetic center of the brain
stem.
o Uncontrolled nausea and vomiting can lead to fluid and
electrolyte imbalance, impaired nutrition, nonadherence to
treatment, and a reduced quality of life.
 Nausea and vomiting can be prevented in 70% - 80% of
patients with the use if antiemetics (drugs that relieve the
signs and symptoms of nausea and vomiting).

3.  There are three patterns of emesis associated with
chemo administration:
1. Acute emesis occurs in the first 24 hours and is the most
severe.
2. Delayed emesis begins 18-24 hours after treatment and
may continue for several days.
3. Anticipatory emesis is a response that is triggered by
chemo-associated sights, smells, visual, thoughts and
anxiety.

4.  Antiemetic guidelines have been developed by the
American Society of Clinical Oncology (ASCO). The
Multinational Association of Supportive Care in Cancer
(MASCC), and the National Cancer Comprehensive
Network (NCCN).
o Acute chemo-induced N&V are prevented and treated with
serotonin receptor antagonists, dexamethasone, and
aprepitant.
o Delayed N&V are treated with dexamethasone and
aprepitant.
o Anticipatory N&V are treated with cognitive therapy and
benzodiazapines.

5. Classes of Antiemetics:
 Serotonin receptor antagonists are the most effective
agents to prevent acute N&V.
o They are administered immediately before chemotherapy
and continued for a few days.
o There are a number of these agents available:
• Anzemet (dolasetron)
• Kytril (granisteron)
• Zofran (ondansetron)
• Aloxil (palonestron)
o The major side effects of these drugs are headache,
diarrhea, fatigue, fever, and drowsiness

6.  Neurokinin-1-Receptor Antagonists:
o These block the NK-1 receptor, which is found in the
vomiting and vestibular center of the brain.
o The only drugs in this class currently available.
1. Emend for injection (fosaprepitant dimeglumine)
2. Emend oral (aprepitant)
o When combined with a serotonin receptor antagonist and
dexamethasone therapy, they have added efficacy in both
acute and delayed N&V.

7.  Corticosteroids
o Dexamethasone is the most commonly used antiemetic
corticosteroid.
o Corticosteroids are important in the prevention of delayed
N&V.
o Common S/E with short term use include insomnia, gastric
irritation, and transient hyperglycemia.

8.  Dopamine receptor antagonists include..
o Reglan (metoclopramide)
o Compazine (prochlorperazine)
o Phenergan (promethazine)
o Haldol (haloperidol)
o Efficacy is low when these agents are used alone, they are
sometimes used in conjunction with other antiemetics for
breakthrough emesis.
 Benzodiazepines
o Benzodiazepines can reduce anxiety some patients experience
before and during chemotherapy.
o They are not antiemetics but are used in conjunction with
antiemetics.

9.  Nonpharmacological Measures to control Nausea & Vomiting:
o There are several nursing measures that may help reduce N&V.
o Patients should avoid eating or drinking 1-2 hours after chemo
treatments.
o Many patients find that foods at room temperature taste better and do
not have as strong of an odor as hot foods.
o Dry toast or crackers in the morning may help the patient’s nausea.
o Clear liquids and herbal tea provide fluids to prevent dehydration.
o Sport drinks also provide electrolytes.
o Liquids should be sipped slowly.
o Some tart foods such as sour hard candy, dill pickles or lemons may be
helpful for some patients.
o Foods such as fried fatty foods or foods with a strong odor should be
avoided.
o Soft, relaxing music; low lights and quiet atmosphere may be helpful.
Some patients do well with diversions such as card games, movies or
crafts.
o Some patients respond well to acupressure, acupuncture, behavior
modification, yoga, massage therapy, hypnosis, and guided imagery.

10.  Myelosuppression
o Myelosuppression is the most common dose-limiting factor
in chemotherapy administration.
o Myelosuppression consists of neutropenia,
thrombocytopenia, and anemia.
 Neutropenia
o Patients with neutropenia have an unusually low number
of neutrophils. Neutrophils attack bacteria and other
organisms when they invade your body. Neutropenia
predisposes the patient to infection.

11.  Thrombocytopenia
o Normal platelet count ranges between 150,000 and 400,000.
Thrombocytopenia occurs when a patient has a low platelet count. The
risk of bleeding increases when the count is below 100,000.
 Anemia
o A patient is considered anemic if the Hgb level is < 8 g/dL. Anemic
patients may be symptomatic or present with headache, dizziness,
lightheadedness, SOB, fatigue, pallor, hypothermia, and pale nail beds
and conjunctiva.
 Fatigue
o Cancer related fatigue is the most common side effect of cancer and its
treatment.
o Exercise may reduce the intensity of fatigue and the distress associated
with its occurrence.
o Treatment of anemia may also be helpful.

12.  Anorexia and Taste Alterations:
o Anorexia and taste alterations are common among patients receiving
chemotherapy.
o Dysgeusia, a condition in which the gustatory sense is impaired. Foods taste
entirely different and in some circumstances even unpleasant.
o Some patients experience a metallic or bitter taste, or no taste at all.
o Advise the patient that gum or hard candy can help between meals.
o Instruct the patient to brush teeth frequently to relieve unpleasant tastes.
o Rinsing the mouth with non irritating mouthwash is often refreshing.
o Cold foods or foods served at room temp are usually tolerated better than hot
foods, cold fruits and cheeses are often a better alternative than a hot meal.
Small more frequent meals may be tolerated better than three large meals.
o Hard, dry food can cause discomfort and be difficult to swallow as compared
to soft meals.
o Commercial mouthwashes, smoking, and alcohol are irritating to the mucous
membranes and should be avoided.

13.  Nursing suggestions to help patients cope with taste
alterations:
o Provide oral hygiene before meals.
o Avoid strong cooking odors, such as cabbage and broccoli.
o Arrange food attractively.
o Eat in pleasant, relaxed environment.
o Use pleasant odors, such as cloves.
o Avoid noxious odors, such as fish.
o Enhance food flavors with herbs, spices, or marinade.
o Serve cold foods rather than hot foods.
o Eat frequent, small meals.
o Administer antiemetics before meals.
o Drink high energy shakes.
o Serve food on glass dishes and use plastic silverware.

14.  Constipation
o Constipation is the difficult, and sometimes painful, passage of
hard, dry stool. It can vary from mild discomfort to the
development of a paralytic ileus.
o There are many causes including Chemotherapy, anxiety,
depression, opioids, muscle relaxants, hypercalcemia,
immobility, dehydration, dietary deficiencies, and tumor
involvement.
o Patients at risk for constipation should be instructed to increase
their dietary intake of fresh fruits, vegetables, and fiber. The
patient should has at least 2 to 3 liters of fluid daily unless
otherwise contraindicated.
o Cheese, eggs, chocolate, candy, and foods known to be
constipating should be avoided.
o Physical activity and exercise stimulate peristalsis, patients
should be encouraged to remain as active as possible.
o Patients should be instructed to respond to the urge to defecate
and not wait.

15.  Diarrhea
o Diarrhea is the abnormal passage of five or more loose or watery
stools in a 24 hour period, often it is accompanied by abdominal
cramping.
o Patients with 6 or more diarrhea stools a day are at risk for
dehydration and electrolyte imbalance.
o Instruct the patient to increase their intake of constipating foods
such as cheese and eggs.
o Foods high in pectin, bulk, and fiber help slow peristalsis. Fluid
replacement prevents dehydration.
o Avoid spicy foods, which irritate the GI tract.
o Advise patients that fatty or greasy foods stimulate the colon.
o Raw fruits and vegetables, nuts, caffeine, seeds, popcorn, and
alcohol should be avoided.

16.  Diarrhea (cont’d)
o Intake and output should be accurately recorded.
o Potassium is one of the major electrolytes lost;
therefore fluids and foods high in potassium should
be used.
o Pharmacological intervention should be started as
soon as possible to avoid complications.
o In cases of severe diarrhea, IV fluid replacement and
anti motility agents (such as loperamide ,
diphenoxylate, or octreotide) may be indicated.

17.  Alopecia
o Although hair loss is temporary, alopecia may adversely affect
self image.
o Rapidly dividing cells, including the hair follicles, are affected by
chemotherapy.
o Hair loss may be thinning, partial, or complete, and may involve
the scalp, eyebrows, and eyelashes.
o Hair loss may begin in 7-10 days after treatment, but sometimes
begins even before treatment is completed.
o Regrowth usually occurs 3-6 months after the last treatment.
o Care of the scalp should be the same as that for any area of
exposed skin.

18.  Stomatitis and Mucositis
o The mucous membranes of the GI tract, especially those of the mouth,
can become red, irritated, and inflamed.
o Stomatitis can range from a mild irritation to full blown sores, with
difficulty swallowing.
o Chemo related stomatitis usually begins 5-7 days after treatment and
lasts about 10 days.
o Educate patient on good oral hygiene.
o A soft toothbrush should be used, particular when mouth is tender.
o Advise patients to remove their dentures at night and as much as
possible during the day.
o Instruct patients to eat soft foods with a smooth consistency. Cold foods
may be soothing to irritated membranes.
o Applying lip balm deeps the lips moist and promotes comfort and
healing.
o Ice chips have been used effectively to prevent or reduce mucositis in

19.  Cardiotoxicity
o Cardiotoxic chemo agents include the anthracyclines,
doxorubicin and daunorubicin, mitoxantrone, paclitaxel, and, in
high doses, cyclophosphamide.
o The anthracyclines can damage the myocytes, weakening the
cardiac muscle. This results in decreased cardiac output, with
progression to congestive heart failure.
o A patient is usually asymptomatic until s/s of CHF appear.
Patients c/o SOB, especially on exertion, and a nonproductive
cough.
o The physical exam shows neck vein distention, tachycardia,
gallop rhythm, and edema.
o A drop in the baseline ejection fraction signals a decrease in left
ventricular function. At this point one must weigh the risk of
cardiac damage against a meaningful tumor response.
o Frequent monitoring of the EKG helps to identify early sign of
impending toxicity.

20.  Neurotoxicity
o Neurotoxicity may affect the central nervous system or the
peripheral nervous system.
o CNS toxicity includes encephalopathy, seizures, cerebellar
dysfunction, mental status changes, opthalmic toxicity, and
ototoxicity.
o Peripheral toxicity causes axonal degeneration or
demyelination involving sensory and motor dysfunction.
o Paclitaxel, cisplatin, carboplatin, and the vinca alkaloids
are the agents most likely to cause neurotoxicity.
o Peripheral neuropathy usually does not occur until after
five or more treatments.
o As the toxicity increases, the patient complains of muscle
pain, weakness, and disturbances in depth perception,
particularly with ambulation.

21.  Neurotoxicity- cont’d:
o Patients need to be cautioned about loose rugs, steps, and
articles lying on the floor that may cause the patient to trip.
o Because there is a decrease in sensation, the patient needs to
use caution when using hot water, heating pads, electric
blankets, hot stoves, and radiators.
o Exposure to cold is also a concern. Patients should dress warm
and use protection against the cold on their hands and feet.
o Paralytic ileus and constipation are also concerns of this patient
population.
o Symptoms can manifest within 2 days, and especially in patients
receiving vinca alkaloids.
o The patient should be observed for abdominal distention and
active bowel sounds. Fresh fruits and vegetables, fiber, and
fluids should be added to the diet. Constipation may be
compounded in the patient who is also receiving narcotics. Stool
softeners may be helpful

22.  Renal Toxicity:
o Chemotherapeutic agents that may cause renal toxicity are
cisplatin, carmustine, streptozocin, methotrexate, mytomycin-cm
and, to a lesser degree, carboplatin. Concurrent administration
of amphotericin, aminoglycoside antibiotics, and vitamin c
potentiates nephrotoxcity.
o BUN and creatinine levels need to be obtained prior to
administration of the nephrotoxic agents.
o Vigorous hydration is often administered before nephrotoxic
agents. Mannitol and Lasix may also be given to promote
diuresis.

23.  Pulmonary Toxicity
o A few chemotherapy agents can damage the endothelial cells of
the lung. Bleomycin at dosages exceeding 400 units and
carmustin in total doses of 1500mg/m2 predispose patients to
pneumonitis and interstitial fibrosis. Toxicity can be increase with
concurrent use of cyclophosphamide. Other agents include
mitomycin and methotrexate.
o The patient usually presents with dyspnea, a nonproductive
cough, fatigue, and fever. Lung sounds produce inspiratory
bibasilar rales.
o Elderly patients and patients with a smoking history, or a
pulmonary condition appear to be at greater risk for pulmonary
toxicity.

24.  Sexual and Reproductive Malfunction
o Chemo adversely affects gonadal function. Preservation of
fertility is an active area of research.
o In males, chemo reduces the sperm count and temporary or
permanent infertility may result.
o Chemo suppresses ovarian function in women. Within 6 months
of receiving chemo, women may experience amenorrhea or
changes in their menstrual cycle.
o Many women experience s/s of a medical menopause, including
hot flashes, irritability, insomnia, and vaginal dryness.
o Gametes or embryos may be frozen before chemotherapy.
o There is also interest in protecting the ovaries by using a
gonadotropin-releasing hormone analogs during chemotherapy.